Understanding Subfertility: Causes, Diagnosis, and Management

Subfertility is defined as the failure to conceive after one year of regular, unprotected intercourse. Causes include ovulatory disorders, tubal factors, uterine factors, male factors, and unexplained factors. Diagnosis involves assessing ovulation, tubal patency, uterine abnormalities, and semen analysis. Management strategies depend on the underlying cause and may include medical interventions, lifestyle changes, and assisted reproductive technologies.

• Subfertility
• Reproductive system
• Causes
• Diagnosis
• Management

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1. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Academic year 2021-2022 3rd year S 5 REPRODUCTIVE SYSTEM MODULE Session: 7 Lecture: 3 Duration : 1 hour SUBFRTILITY Presented by Dr.RAYA MUSLIM AL HASSAN Module staff: Dr.Raya Muslim Al Hassan (module leader) Dr.Nada H Al Jassim Dr.Alaa Hifthi Dr.Nawal Mustafa Abdulah Dr.Marwa sadik Dr.Nehaya Mnahi Al Aubody GYNAECOLOGY 20th EDITION by Ten Teachers

2. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College What is subfertility? Subfertility is the failure of conception in a couple having regular, unprotected coitus for 1 year PRIMARY Couple without a prior pregnancy SECONDARY Couple with previous pregnancy including miscarriage/ectopic 75-80% of couples there will be pregnancy after 12 cycles 90-95% of couples will be pregnant after 2-3 years.

3. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Causes :- A - Female 30% 1- ovulatory disorders : - The commonest cause is polycystic ovary syndrome (PCOS) Hypothalamic disorders e.g. Hypothalamic hypogonadism) . Pituitary disease (e.g. Hyperprolactinaemia). Endocrine abnormalities (thyroid disease) . 2- Tubal factors :- (PID, previous surgery, endometriosis) 3- Uterine factors :- (fibroid, adhesions) 4-Peritoneal (endometriosis). 5- Cervical factors .

4. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College B -Male 30% Compromised sperm number or quality is an important contributor to subfertility. ( Mainly unknown cause ) . - Possible causes :- Environmental and dietary issues. Infections :- ( Orchitis , epididymitis ) Iatrogenic :- pelvic radiotherapy or surgery for undescended torted testes . Medical conditions such as diabetes . Occupational factors :- contact with chemicals , radiation or heat . Erectile difficulties or problems with ejaculation. Genetic : aneuploidy of sex chromosomes (Klinefelter XXY most commonly) C - Mixed 15% D -Unexplained 25% or

5. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College History & examination

6. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College INVESTIGATIONS Female Assess ovulation . Tubal patency . Uterine abnormality . Male Semen analysis . Hormonal analysis(T, FSH, LH) +/-Karyotyping

7. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College ASSESSING OVULATION 1)History (regular cycle, dysmenorrhoea, breast engorgement) 2)Basal body temperature chart 3)Hormonal study -Serum progesterone (mid luteal phase ie day 21 of 28-days cycle) - LH/FSH levels -E2, Testosterone levels PCOS -Prolactin -Thyroid tests - Serum AMH

8. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College 4) Ultrasound Assess ovulation (by tracking the size of follicle) U/S of the ovary at day 13 of cycle showing the pre- ovulatory dominant follicle size of 20 mm (normal 18-22 mm)

9. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College ASSESSING UTERINE/TUBAL PROBLEMS Hystero-Contrast - Sonography (HyCoSy) HSG/hysterosalpingoigr aphy

10. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Laparoscopy + dye test (chromotubation) if tubal blockage seen in HSG

11. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College ASSESSING PERITONEAL FACTORS Laparoscopy endometriosis

12. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College INVESTIGATIONS (MALE) Semen analysis Needs prior appointment with lab Abstinence 2-4 days. Complete collection of the semen Transport to lab in 1 hour Put it in incubator 37 c or at room temperature.

13. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College

14. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College TREATMENT Fertility treatment should be individualized to optimize the treatment result, Management may be expectant, medical, surgical or combination of these.

15. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College OVULATION INDUCTION 1) Normogonadotrophic anovulation (PCOS). Anti- oestrogens e.g Clomiphene/ Tamoxifen Metformin Gonadotrophins 2) Hypogonadotrophic hypogonadism Pulsatile GnRH Gonadotrophins with LH activity Bromocriptine ( for hyperprolactinaemia) 3) Laparoscopic ovarian drilling 4) Luteal phase support-progesterone

16. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Peritoneal/Uterine/tubal problems Endometriosis:Laparoscopic surgical ablation/ resection of spots + adhesiolysis . Uterine factors: hysteroscopic adhesiolysis for Asherman s syndrome ,myomectomy for fibroid . Tubal factors: Laparoscopic tubal surgery or IVF .

17. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Treatment of male subfertlity According to the cause

18. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Intra-uterine insemination(IUI): injection of activated semen inside the uterus by a catheter

19. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College